California Insurance Lawyer Blog

Our First Guest Blog: Daniel Malito writes about struggles with getting his pain medication paid for

Fri, 17 May 2013 10:00:06 -0800

Insurance woes. Many of us have heard about a “friend of a friend,” or “some guy” who has been well and truly abused by their health insurance company. We all have the same response -- “that’s horrible,” or something to that effect. Luckily, though, most never get the pleasure of dealing with insurance shenanigans first hand. Well, I’m here to tell you that real people do have to deal with health insurance B.S., for lack of a better word, and it can range from being mildly annoying to thoroughly life-changing.

I was diagnosed with Rheumatoid Arthritis when I was nine. In 1987, before compact discs, the PC, and MTV, I was a mere third-grader who, we thought, had simply caught a bad case of the flu. After several weeks of harboring this “flu” without improvement, the doctors began to look for other causes. To cut a two-year story very short, let’s just say that I was diagnosed with something called Juvenile Rheumatoid Arthritis when I was eleven. My mother diligently spent hours upon hours reading and researching the disease at libraries all over – the “Wikipedia” of the real world at the time. Unfortunately, as is still true today, doctors did not have any idea what caused the illness. So, as one of the first serious cases of the disease in my area, my parents and I went from doctor to doctor, agreeing to test after test, just on the off chance one of the procedures would provide some insight into the ailment that was previously unknown. That never happened, though, and I went from a child with Juvenile Rheumatoid Arthritis to an adult with plain old R.A.

Throughout my childhood and early adulthood, I was lucky enough to be covered by what could be called a “Cadillac” insurance plan. I was able to choose my own doctors, purchase experimental medication, and have any procedure performed without pre-authorization. I cannot imagine what would have happened if we had to fight my health insurance company in those uncertain initial years – I could have ended up in a wheelchair. I tell you this because I want you to understand that I have experienced the good side of health insurance as well as the bad, and the difference is striking.

Eventually the Cadillac plan became too expensive to sustain. Because I was officially disabled, I was also automatically enrolled in Medicare. Because Medicare is always the primary insurance, I was basically paying upwards of $12,000 dollars a year for secondary insurance. So I dropped the Cadillac plan and Medicare became my sole insurance carrier.

Now, I have to take this opportunity to tell you that Medicare is one of the best insurance carriers I have ever dealt with – but that classification comes with two corollaries. First, it must be said that I suffer from a disease that is on the Medicare short list for ailments that are allowed a very large amount of leeway when it comes to insurance claims. Second, I am only talking about hospital stays, doctor’s visits, and medical procedure coverage. Prescription coverage is an absolute and utter nightmare.

For those of you who don’t know how Medicare works here is a brief summary. Part A is the hospital coverage, which covers hospital stays and part B is the actual medical insurance, which covers doctor’s visits and the like. Both of those parts pretty much take care of themselves and are more or less painless in their execution. Part D, though, is the prescription coverage, and even understanding it is a Rubik’s Cube of donut holes, external medical insurance companies, and denial appeals.

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Transparency in Insurer Claim Approval and Denial Rates - Claim Denials Seem to Lead to Greater Profit

Wed, 15 May 2013 14:05:21 -0800

Like the average consumer, we are always curious about the claim approval and denial rates of health insurance companies. A new law in Vermont satisfies that curiosity by requiring health insurers who do business in Vermont to disclose claim denial rates. Not surprisingly, the insurer with the largest profit also had the highest denial rate. Blue Cross Blue Shield of Vermont denied 7.6% of claims, MVP denied 15.5% of claims, and Cigna denied 21% of claims. Blue Cross and MVP are non-profit companies and Cigna is a for-profit corporation.

The most alarming statistic is that of the 377,352 claims that were denied last year (as reported to Vermont) there were only 456 post-service appeals. That means that 99.8% of all denied claims are never appealed. What this really means is that health insurers are winning the fight unless insureds are willing to step up and hold insurance companies accountable for benefits that are available and payable under the policy. As the Vermont Public Interest Research Group (VPIRG) reported, “These numbers confirm what we already knew, that insurers have little disincentive to deny claims when there is such a miniscule chance that these denials will actually be appealed.”

Congratulations to Kantor & Kantor’s Associate Brent Dorian Brehm for being named 2013 “Lawyers on the Fast Track” by the Recorder

Sat, 11 May 2013 11:44:07 -0800

Brent Dorian Brehm, a seventh year associate of Kantor & Kantor LLP, was recognized by The Recorder as part of their 2013 Lawyers on the Fast Track list - which recognizes California’s young emerging legal leaders.

Unlike many other honors in the legal field, this list considers both a lawyer’s body of significant legal achievements and their achievements in serving the larger community. As such, this award sets Mr. Brehm apart from his peers, highlighting a body of motion and trial experience few attorneys have compiled to this point in their career while recognizing the work he has performed in the greater Los Angeles community.

Mr. Brehm has spent his entire career advocating for individual’s rights to disability, life, health, and long term care insurance benefits with one of the preeminent firms in the area of ERISA (Employee Retirement Income Security Act) and bad faith insurance litigation, Kantor & Kantor, LLP. While with the firm, Mr. Brehm has resolved well over 150 disputes with insurance companies on behalf of his clients, and has made the transition to lead attorney on many of his cases. At least 13 nationally reported decisions in his client’s favor (including five cases published in the official reporter and five trial judgments in which Mr. Brehm was lead counsel) speak as testament to Mr. Brehm’s advocacy skill and experience gained through practice.

In addition to his many legal accomplishments, Mr. Brehm gives back to his community. When not practicing law, Mr. Brehm enjoys volunteering for Reading to Kids, an organization dedicated to helping inspire a love of reading in children from underserved portions of inner-city Los Angeles. Mr. Brehm was recognized by Reading to Kids when it named him as a recipient of the Distinguished Volunteer award. This effort to better serve the underprivileged members of his community has its roots in Mr. Brehm’s early volunteer activities with the Mexico Orphanage Mission and Food Not Bombs. After law school, his efforts sprouted into working to improve the quality of life for the homeless through work with the East San Gabriel Valley Coalition for the Homeless. On an international level, Mr. Brehm has paired his love of cycling with World Vision’s Bikes for Africa project: helping raise awareness for the project in addition to offering financial support.

After careful review of the professional and civic achievements from nearly 200 California attorneys in their first 10 years of practice, Mr. Brehm was selected as a top contributor to the practice of law and to his community. Mr. Brehm is honored to be recognized by The Recorder. Earlier this year Mr. Brehm was recognized by the Los Angeles and San Francisco Daily Journal, as part of their “Top 20 Under 40” list as a rising star in the California legal industry. Mr. Brehm is proud that these publications, through such awards, recognize the importance, skill, and dedication of all ERISA attorneys in protecting the rights of claimants.

See an online version of the Recorder’s announcement here: http://www.law.com/jsp/ca/PubArticleCA.jsp?id=1202596780843&Introducing_50_California_Lawyers_on_the_Fast_Track&slreturn=20130319154839. Be sure to check a special edition of The Recorder on June 24th for the full profile.

To learn more about Mr. Brehm and the firm of Kantor & Kantor see www.kantorlaw.net or call (800) 446-7529.

Your Insurance Company Pays Less Than You Think

Fri, 10 May 2013 11:08:55 -0800

If you have long term disability insurance through your employer, you probably know that you are entitled to a benefit if you ever become unable to work because of injury or sickness. The amount of the benefit varies, but it is typically 50-60% of your salary.

However, what you may not know is that most long term disability benefit plans usually don’t even pay that much. Why? Because most plans contain “offset” provisions.

What are offset provisions? Offset provisions state that if you are receiving money for your disability from other sources, the plan can reduce your benefit by that amount. Typically, benefit plans contain offsets for such things as state disability benefits, Social Security disability benefits (both SDI and SSI), and worker’s compensation benefits, among other things. Plans can even offset for income that isn’t related to your disability, like pension benefits.

If this is all new to you, you might want to get an idea of how this offset could work for Social Security Disability Benefits. You can go to the SSA website to calculate an estimated benefit, which you can then use to estimate how the offset would reduce your long term disability benefit. Visit the SSA site here: http://www.ssa.gov/OACT/quickcalc/index.html

Because most people are entitled to at least one other form of disability benefit, this means that your employee benefit is usually not even the 50-60% amount stated in the benefit plan – it’s actually less. In fact, in some cases, your benefits from other sources can be large enough that your employee benefit is reduced to zero. Some plans will still pay a nominal minimum benefit in such cases, but some do not. In other words, even though you are disabled and eligible for an employee disability benefit, your benefit amount could be nothing at all.

Because the amount of your employee benefit is dependent on your receipt of other benefits, you must be very careful in deciding whether to apply for other benefits, and if so, how to do it. Realize however, that sometimes, you may not even have a choice as your disability plan may require you to apply for these other benefits. As employee benefit specialists, we can help if you have questions. If an insurance company is reducing your benefit because of offsets, and you think they have made a mistake, please contact us.

Kantor & Kantor proves that Unum unlawfully denied long term disability benefits to policyholder suffering from fibromyalgia

Wed, 08 May 2013 11:33:04 -0800

In January of this year, Kantor & Kantor secured a judgment against Unum Life Insurance Co. http://www.unum.com/, a Fortune 500 company and the largest group and individual disability carrier in the United States. (click here for a copy of the ruling Mondolo v. Unum Life Ins. Co. of Amer., C-11-07435 CAS (MRWx) (C.D. Cal., order filed January 16, 2013). http://www.kantorlaw.net/documents/59-Mondolo-13-01-17-Findings-of-Fact-Order.pdf

Our client, a resident of Los Angeles County, was suffering from fibromyalgia and avascular necrosis (aka bone death, believed to be a result of leukemia treatment). She had been treating for these conditions at U.S.C.’s Keck School of Medicine and had been on disability since July 2009. After paying long term disability benefits for over a year, Unum terminated our client’s disability benefits. Unum’s Gilberto Del Real determined that our client was not disabled because she was capable of working in a sedentary occupation. After our client appealed, Unum’s Stephanie LeSieur also erroneously concluded that our client was capable of sedentary work.

“Like so many group disability insurers, Unum labored under a structural conflict of interest because Unum has both the duty to determine whether claimants qualified for benefits and the responsibility for paying those benefits,” said Kantor & Kantor partner Alan E. Kassan
, who assisted associate Brent Dorian Brehm on the case. “Unum’s bias led the court to review Unum’s decision regarding our client’s benefits with enhanced skepticism and the denial could not withstand scrutiny.”

Kantor & Kantor was able to prove that Unum’s structural conflict of interest had contributed to its decision to terminate his client’s disability insurance benefits. In reaching its decision, the court noted Unum’s history of biased claims administration and case specific facts that the Kantor lawyers argued aggravated Unum’s conflict of interest. The court found the following:

•Unum failed to properly investigate the client’s claim, neglecting to determine how much sitting she could tolerate without significant pain.
•Unum did not investigate whether the alternative jobs it claimed our client could perform were appropriate for her limited ability.
•Unum and its reviewing physicians failed to consider psychological evidence, even though the policy expressly stated that such evidence must be considered.

In addition, attorneys Kassan and Brehm argued that Unum’s conclusions were unreasonable. For example, Unum insisted our client could sit between one-third and two-thirds of a work day. The Kantor attorneys proved even if Unum’s supposition was accurate, our client was still not able to meet the requirements of, or perform the sedentary work for which Unum argued she was capable.

Click here http://www.kantorlaw.net/Cases_Resources/Document_Library.aspx to learn more about this case.

At Kantor & Kantor, we spend every working day doing one thing: helping people resolve disputes with their insurance companies. Life is difficult enough for people living with chronic illness, and we understand that being denied disability coverage by your insurance company or employer only exacerbates the situation. If you are in need of the services we provide, please call us at (800) 446-7529 for a no-cost consultation or go to www.kantorlaw.net for more information.

Obtaining insurance coverage for human growth hormone treatment for Idiopathic Short Stature (ISS)

Wed, 08 May 2013 11:19:22 -0800

In 2003, the Food and Drug Administration approved the use of growth hormone (GH) for the long-term treatment of idiopathic short stature (ISS), which refers to extreme short stature that does not have a diagnostic explanation, such as GH deficiency. Unfortunately, GH treatment is expensive and, as a result, insurance companies often resist paying for it.

Follow this link to an article we have prepared which discusses how ISS is defined, how it is diagnosed, how insurance companies try to avoid payment for it and how we respond to the insurance companies’ arguments: http://www.kantorlaw.net/documents/Article-on-HGH-treatment-DJO-4-5-13-pdf.pdf

Disability is Real: Correcting distorted perceptions around diagnosis, symptoms, and life with a disability

Mon, 22 Apr 2013 10:04:05 -0800

In August 2012, Kantor & Kantor posted this blog on the unfounded assertion that receiving disability insurance is a positive substitute for gainful employment: http://www.californiainsurancelawyerblog.com/2012/08/ridiculous_to_claim_disability.html

More recently, we encountered NPR’s week long series titled, “Unfit for Work: The Startling Rise of Disability in America." This series advanced a number of misleading thoughts about living and working with a disability. These include:

1. The implication that people with disabilities are either taking advantage of government assistance or being victimized by it.
2. The failure to explain why people might have the same diagnosis, yet experience symptoms that differ in severity and impact on daily living.
3. A false impression expressed about how disability is actually determined, suggesting that one’s personal physician can make this claim without the involvement of insurance investigations, background checks, medical examinations, medical/employment/financial records, interviews by insurance companies, etc.

As attorneys who represent clients with various types of chronic illnesses, we have come to appreciate the devastating and painful effects of life with a disability. Those who disparage the necessity of Social Security Disability Insurance (SSDI) and disability insurance, which our clients depend on, have probably never suffered from a chronic disabling condition nor had a loved one disabled by disease. Beyond the physical impact, our society has a long history in which many people acquire a sense of identity and purpose from their occupation. This is lost when they become disabled. Additionally, this is a space where many social relationships are formed as a result of job-related interactions. When illness forces you to prematurely leave your occupation, this experience can be just as painful and isolating as being diagnosed with a debilitating illness.

Before assuming that disability has become “a de facto welfare program for people without a lot of education or job skills,” it is important to consider the reasons for the rise in disability claims. Firstly, baby-boomers are aging, and with age comes a host of disabling conditions. Also, during the past 40 years, more and more women have entered the workforce. Although medicine can’t explain why, women tend to be impacted more than men by some severely disabling conditions. Both of these factors will drive up the number of disability claims.

Charles Martin and Debra Shifrin from the National Organization of Social Security Claimants' Representatives (NOSSCR) have said that “Disability benefits protect the most vulnerable members of our society, who have no other options.” We couldn’t agree more.

If your long term disability claim has been denied, contact Kantor & Kantor for a no-cost consultation at (800) 446-7529. We understand, and we can help.

Information Processing Impairments in Chronic Fatigue Syndrome

Fri, 19 Apr 2013 10:45:18 -0800

Chronic fatigue syndrome (CFS) is a long-term and debilitating condition that affects at least one million Americans. The symptoms are complex, often including intense physical and mental fatigue (usually made worse by exertion), muscle and joint pain, disturbed sleep, and both concentration and memory problems.

Chronic fatigue syndrome derives its name from its dominant symptom – fatigue. However, CFS has eight other official symptoms:
• Loss of memory or concentration
• Sore throat
• Enlarged lymph nodes in your neck or armpits
• Unexplained muscle pain
• Pain that moves from one joint to another without swelling or redness
• Headache of a new type, pattern or severity
• Unrefreshing sleep
• Extreme exhaustion lasting more than 24 hours after physical or mental exercise

Those who suffer from CFS can experience debilitating cognitive dysfunction and mental fatigue. This is commonly referred to as “brain fog.” A recent research study found that the main cognitive disruption in those living with CFS was attributed to slow information processing. After comparing several types of cognitive dysfunction between control subjects and those with CFS, they found information processing speed and reaction time to be impaired in those with CFS.
Interesting to note, researchers discovered that information processing problems did not seem to be a consequence of psychiatric status, depression, anxiety, the number or severity of CFS symptoms, fatigue, sleep quality, or everyday functioning. While the CFS group showed impaired reaction time, they displayed comparable performance on attention, memory, motor function, verbal ability, and spatial ability (even though these remain commonly reported problems in CFS) to the control subjects. The significance of these findings is unclear, but prompts us to consider the relationship between the cognitive symptoms of CFS and information processing difficulties.

While parts of CFS and its relationship with its symptoms are not yet fully understood by the scientific community, studies continue to show that the symptoms and life altering effects are real. Many of our clients have been deeply impacted and disabled by the cognitive and physical symptoms of CFS. Their complaints of extreme fatigue, pain, and cognitive impairment are often dismissed by insurance companies in deciding claims. Often this is because there is no single diagnostic test to confirm the illness.

If your CFS has adversely affected your ability to work, contact Kantor & Kantor for a no-cost consultation. We can help. Find us at www.kantorlaw.net or call (800) 446-7529.

Kantor & Kantor Supports Parkinson’s Disease Awareness Month

Thu, 18 Apr 2013 16:37:16 -0800

On March 29, 2012, the United States Senate officially declared April as Parkinson's Disease (PD) Awareness Month. With many clients who suffer from Parkinson’s Disease, Kantor & Kantor recognizes the magnitude of this illness and the importance of dedicating this month to research, promoting awareness, and spreading information about the disease.

The Parkinson’s Disease Foundation (PDF) is an organization with the mission to find a cure, to advance research, to increase knowledge, to empower the community and to ensure that those living with the disease enjoy the best quality of life possible. See http://www.pdf.org/en/mission

This organization offers valuable information for our clients and their families on topics that include: understanding the illness, coping with a recent diagnosis, managing PD and support for care partners and family. These are just a few examples of the many resources available on the PDF’s website. See http://www.pdf.org/.

In addition to providing assistance with coping with PD, the website can also serve as a valuable resource for those who choose to make a disability claim. If you have been diagnosed with PD, and the symptoms of the disease and side effects of treating medications becomes disabling, you might want to consider submitting a claim for disability benefits through your private or employer-provided disability plan.

Unfortunately, insurance companies don’t always understand how devastating and life changing this illness can be. If your Long Term Disability claim is denied, The Parkinson’s Disease Foundation can be used as a valuable resource when researching how to prove to your insurance company that your condition and its symptoms are disabling. One requirement of most disability policies is that the claimant be undergoing ongoing treatment for the disabling condition. This website provides information that helps you to understand exactly what type of care that is.

If you get your insurance coverage through your employer, as most people do, you fall under the umbrella of ERISA (Employee Retirement Income Security Act). Under the Employee Retirement Income Security Act, you have a legal right to appeal the denial of disability benefits. The burden and responsibility of proving your claim becomes yours. It is crucial for you to create a record of documented evidence during the appeal in case litigation becomes necessary in the future. Do NOT rely on your insurance company to help you.

Managing an appeal on your own can be risky if you are not physically or mentally capable. If the case becomes too complicated to handle on your own, you may want to seek out advice from a professional. Kantor & Kantor has a team of experts that work on a on a contingency fee basis, which means you only pay if we obtain a benefit for you. We understand the struggle of living with a chronic disease, and we are here to help. For questions about your long term disability claim, call (800) 446-7529.

Kantor & Kantor Associate Named one of “Five Associates to Watch” by the Daily Journal

Thu, 14 Mar 2013 11:27:02 -0800

Brent Dorian Brehm, a seventh year associate of Kantor & Kantor LLP, was recognized by the Los Angeles and San Francisco Daily Journal, as part of their “Top 20 Under 40” list of California’s emerging legal leaders, as a rising star in the California legal industry. Mr. Brehm has spent his entire career advocating for individual’s rights to disability, life, health, and long term care insurance benefits.

Mr. Brehm has spent his career with one of the preeminent firms in the area of ERISA (Employee Retirement Income Security Act) and bad faith insurance litigation, Kantor & Kantor, LLP. While with the firm, Mr. Brehm has resolved well over 150 disputes with insurance companies on behalf of his clients. As a litigation associate, Mr. Brehm has developed a body of motion and trial experience few attorneys have compiled to this point in their career.
At least 13 nationally reported decisions in his client’s favor (including five cases published in the official reporter and five trial judgments in which Mr. Brehm was lead counsel) speak as testament to Mr. Brehm’s advocacy skill and experience gained through practice.

Having established a track record of success early in his career, Mr. Brehm has made the transition to lead attorney on most of his cases. In one such case litigated in San Francisco, Mr. Brehm secured the first trial judgment in the nation on behalf of a plan participant against AT&T’s long term disability plan in the hotly contested case of Peterson v. AT&T Umbrella Ben. Plan No. 1, 2011 WL 5882877 (N.D. Cal. 2011). Last month, in a case tried in Los Angeles, Mr. Brehm received another favorable trial judgment, this time against Unum Life Insurance Company – the largest group disability insurer in the United States. (Mondolo v. Unum, 2013 WL 179711 (C.D. Cal. 2013)).

To learn more about Mr. Brehm and the firm of Kantor & Kantor see www.kantorlaw.net or call (800) 446-7529.

Kantor & Kantor Recognizes the Challenges of Multiple Sclerosis: MS Awareness Month 2013

Tue, 12 Mar 2013 11:19:13 -0800

In 2006, March was designated MS (Multiple Sclerosis) Awareness Month. This year, the National Multiple Sclerosis Society spreads awareness by emphasizing the impact of connection. While MS destroys the connection between the body and mind, and between people, advocates can strengthen and encourage connections through sharing knowledge and information.

According to the National MS Society:
• There are currently 2.1 million people living with MS.
• Every hour of every day someone in the U.S. is diagnosed with MS.
• Most people are diagnosed in their 20’s or 30’s…but it lasts a lifetime.
• There is no cure.

What is MS?

MS is a chronic disease that strikes the central nervous system (CNS). The immune system attacks the CNS leading to damaged nerve fibers. This damage creates scar tissue (sclerosis), and distorts the nerve impulses traveling to and from the brain and spinal cord. The flow of information between the brain and body is interrupted. The symptoms can be disabling- affecting the brain, spinal cord, and optic nerves. MS presents itself differently for each individual, and its severity and symptoms are difficult to predict.

Each year at this time, advocates come together to spread awareness, raise funds for research, and offer support and connections within the MS community. At Kantor & Kantor, many of our clients suffer from MS, and seek our assistance when their disability benefits have been unfairly denied. We understand that living with MS can be painful, difficult, and challenging. Being denied benefits by your insurance company only aggravates an already complicated condition. Contact our office at (800) 446-7529 or on www.kantorlaw.net if your claim has been denied. We can help.

Kantor & Kantor Recognizes the Challenges of Multiple Sclerosis: MS Awareness Month 2013

Tue, 12 Mar 2013 11:19:13 -0800

What is MS?

Delays by the Insurance Company During an ERISA Appeal

Thu, 28 Feb 2013 12:16:40 -0800

The Regulations governing ERISA claims have time limits governing the claim and appeal process. According to the Regulations, a claimant has a minimum of 180 days to appeal a denied disability claim. An insurer must decide the appeal within 45 days, or if “exceptional circumstances,” exist, may request an additional 45 day period to decide the appeal.

Recently, we have seen insurers attempt to obtain additional time by delaying or “tolling” the appeal, while they purportedly obtain additional information from third parties (such as an “independent” medical examination). We believe that any delay due to a request for third party information is an insufficient basis to “toll” the time for conducting an appeal and is an improper delay of the appeal process.

The Regulations do permit an insurer to “toll” an initial claim, while they request and wait for records or information. However, once a claim has been denied and it has been appealed, an insurer may not extend the deadlines, by claiming that it needs additional information from third parties. Rather, the time for deciding an appeal may not be “tolled” unless the insured has failed to submit information to decide a claim. 29 C.F.R. 2560.503-h(i)(4).

Don't let your insurance claims administrator take advantage of you, and delay the payment of your benefits longer than the law allows. Insist that they comply with the regulations and communicate with you in a timely manner. If you let them know that you are an educated consumer, the odds are that they will attend to your claim more carefully.

Of course, if you ever have any questions. Call us, we can help!

Alzheimer’s Cases Projected to Triple in Next Forty Years, With Care Costs Exceeding $1 Trillion

Tue, 26 Feb 2013 18:10:01 -0800

The American Academy of Neurology published a report in its journal Neurology predicting that many more people than previously thought will become disabled by Alzheimer’s disease, the total number reaching 13.8 million by 2050 and costing more than $1 trillion a year to treat. See, “Alzheimer’s cases, costs, projected to swell.”

“The growth in new cases – especially as baby boomers pass the age of 75 – will put pressure on generations behind them to provide massive amounts of care,” writes Los Angeles Times reporter Joseph Serna.

The federal government is spending hundreds of millions to fund research for development of drugs to treat the disease. The National Alzheimer’s Project was founded in 2011 to ask public, private and nonprofit groups to come up with treatment plans and ways to help caregivers tasked with the overwhelming responsibility of caring for family members with Alzheimer’s. This is all important work.

But for now, one of the few resources many rely on for the expenses of care, other than family and friends, is long-term care (LTC) insurance. And even people who have LTC insurance often have to fight for benefits. Nothing can be more frustrating, or even devastating, than when you are not able to obtain the LTC insurance benefits from a policy you have paid premiums on for years.

If you are stuck in the cycle of insurer delays and denials for long-term care, disability, health or life insurance benefits, call us at (800) 446-7529. We can help.

Tips for Preparing for a Long Term Disability Insurance Benefits Appeal

Tue, 19 Feb 2013 08:59:39 -0800

Many chronic diseases have the potential to flare and fade without much notice. Thus, living with a chronic disease can force changes into your life. For instance, many people suffering from flaring rheumatoid arthritis might be forced to stop working. When this happens, seeking public and private disability benefits may help the financial burden caused by the flare.

Unfortunately, insurance companies have made a regular practice of refusing to pay disability benefits. Once denied, you almost always have the right to appeal the adverse decision.

Here are some valuable tips to consider when preparing your appeal for a group disability insurance benefit under ERISA. Please note that because each claim is unique, this is not a complete list, but simply a reminder of important materials for an appeal.

• Before initiating the appeal process, request your claim file and policy from your insurance carrier or employer. You will need to review your policy: without it, you don’t know the rules!

• Consider what evidence you have to prove that you are not capable of performing your job because of your disability, and include this in your appeal packet. Remember that in an ERISA governed policy, once a decision is made on your final appeal, your file is closed. Any information you leave out may never be heard or considered by a court!

o Personal Statement (make your appeal letter more of a cover letter, telling the insurance company why you disagree with their decision, and what information they will find in your appeal packet that will change their minds)
o ALL Doctors’ records (including side-effects of the treatment of your disabilities, and how those impact your ability to work)
o Attending Physician Statements
o Job description (do not rely on a generic job description provided by your insurance company- they might not use a full and complete list of your actual duties)
o Performance reviews
o Statements from supervisor/co-worker/subordinates, caretaker, family and friends
o Social security award
o Independent medical examination

• Communicating with the insurance company: Try and stay off the phone as much as possible! All communication should be in writing, in traceable forms such as certified mail, fax or e-mail. If you can't prove it, it never happened. Although it’s not always possible, while you are on the phone try to get the name, title, phone number and email address of everyone you talk to. Speaking with different insurance representatives can become confusing and overwhelming. Keep a journal of your conversations so that you can refer back to them later.

• Your appeal has a deadline; don’t miss it! In most cases, failing to appeal before your deadline means that you will be unable to pursue your claim any further.

Supplying your insurance company with the information mentioned above does not guarantee that your disability claim will be approved; however, it does create a documented record of evidence to which you can rely up on if any subsequent litigation ensues. If you have questions about what to include or how to file your appeal, contact Kantor & Kantor at (800) 446-7529 or log on to www.kantorlaw.net.